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NEW MEXICO STATE UNIVERSITY WORKERS' COMPENSATION SUPERVISOR ACCIDENT INVESTIGATION REPORT
(PLEASE PRINT OR TYPE) 1. Location Code: 6. Nature of Accident: ( )Personal Injury ( )Personal Injury & Damage to Property
11. Nature of Damage:

2. Accident Location (Building, Room #, City): 7. Employee Name: SS#

3. Time of Accident: _____AM _____PM 8. Was Medical Treatment Needed?

4. Date of Accident: 9. Part of Body: ( ) L ( ) R ( )Ft ( )Bk
_________________

5.Date Reported to Supervisor:
10. Lost Time? ( ) YES ( ) NO

12. Source of Damage:

13. Witness/Co-Worker:

14. What happened? Describe In Detail. EMPLOYEE ALLEGES...

Carefully Evaluate Job Hazard Analysis and Standard Operating Procedure (SOP) to Answer Questions 15, 16, 17 and 18:

15. What immediate unsafe acts and/or unsafe conditions contributed to this accident?

16. What are the underlying or root causes which allowed the above factor to exist?

17. What actions have or will be taken to eliminate the root cause?

18. Safety Equipment:

(

) In Place (

) Used

(

) Needs Improvement

(

) Not Applicable

19. Reviewed by your Department Safety Office: Signature: Date: Laboratory Safety -Date:

20. Training: Job Specific (task or equipment)-Date: 21. Investigated by: (Immediate Supervisor) Signature: Reviewed by NMSU Safety Office:
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General Safety -Date:

Date: Date:

22. Reviewed by: (Next Level Supervisor/Manager) Signature: OSHA 200:

Date:
Please Return this completed form to Personnel, Box 5273.

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